DOI: 10.5152/cjms.2019.06051
Original Article
Smoking Status among Medical Students of Near East University in Nicosia Özen Asut
Department of Public Health, Near East University Faculty of Medicine, Nicosia, Cyprus
ORCID ID of the author: Ö.A. 0000-0002-9604-4037.
Cite this article as: Asut Ö. Smoking Status among Medical Students of Near East University in Nicosia. Cyprus J Med Sci 2019; (Suppl 1): 1-21.
BACKGROUND/AIMS The objectives of the present study were to evaluate the tobacco prevalence status of Near East University (NEU) Medical school students and to investigate the associations of tobacco use with medical education and other related factors.
MATERIAL and METHODS This cross-sectional study was conducted among all the multinational medical students of NEU in February 2018. A questionnaire was administered to the students under direct observation. Data were analyzed using the Statistical Package for the Social Sciences version 18.0.0 software (IBM Corp.; Armonk, NY, USA). A p value <0.05 was considered as significant.
RESULTS The study targeted all the medical students attending medical school in the educational year 2017–2018. Of a total of 1371 medical students, 1154 (84.2%) were included in the study, of which 48.9% were males and 51.1% were females. Current smokers were 33.7% with 26.5% daily smokers. Lifetime smoking was 40.7% with the inclusion of former smokers. Of the 1154 students, 42.1% and 25.8% were male and female smokers, respectively. There was a significant difference between the two genders, with males smoking more. Regarding admission to medical school, there was a significant difference between the genders, with smoking initiation of women being higher than that of men during medical education. Of the male smokers, 61% had started smoking before admission to medical school. A comparison of the countries of origin revealed a significantly higher frequency of smoking among Turkish Republic citizens than all other country citizens.
CONCLUSION Smoking prevalence among medical students was found to be high, with males smoking significantly more than females. Medical education did not appear to influence the smoking status of medical students, taking into account the high frequency similar to other university students. Earlier and more efficient tobacco control and cessation education and interventions are needed throughout medical education for better role model doctors for the community in the future.
Keywords: Smoking, tobacco control, medical curriculum, medical students
INTRODUCTION Smoking is one of the leading causes of all deaths and the second major preventable cause of death worldwide, ending >7 million lives/year. By 2030, the estimated death toll will increase to approximately 8 million/year (1). One of the best ways to fight against smoking is by counseling provided by general practitioners and other physicians in public health settings (2). However, smoking prevalence among doctors (3) and medical students (4) continues to remain relatively high in a number of countries.
Smoking is a key issue of the medical profession, negatively affecting just about every organ in the body, often ending up with cancers and other incurable diseases, as well as diminishing the quality of life (5-9). Since the first tobacco report of the US Surgeon General in 1964, >20 million premature deaths can be attributed to tobacco consumption, as a result of smoking toxicity due to the 7000 chemical compounds and 69 carcinogens in tobacco smoke (8, 10-13).
Research has shown that physicians and medical interventions can be very effective in the cessation of smoking (14). Hen- ce, doctors should set examples by presenting a non-smoker environment since it is well known that non-smoking doctors have a better chance to succeed in promoting smoking cessation (15, 16).
Corresponding Author: Özen Asut Received: 18.04.2019 E-mail: [email protected] Accepted: 29.04.2019 ©Copyright 2019 by Cyprus Turkish Medical Association - Available online at cyprusjmedsci.com 1 Asut Ö. The Smoking among Medical Students Cyprus J Med Sci 2019; (Suppl 1): 1-21
A review published in 2007 investigated 81 studies published cation and other related factors on smoking habits among me- between 1974 and 2004 about smoking among health profes- dical students enrolled in Near East University (NEU). sionals to determine smoking trend changes. Smoking addiction varied widely through the years and among countries; never- Our study aims at determining the smoking status among medi- theless, smoking among health workers was found to be highly cal students in one of North Cyprus’s (TRNC) universities, NEU prevalent in a number of countries (3). Medical School, in an attempt at forming an idea about how me- dical education, background, family smoking status, and some Medical school students, who are the focus of our research, other factors affect smoking habits of those students. There are were studied in an international review of tobacco smoking no published studies that have been conducted exclusively on conducted in 2007. The prevalence of smoking was found to ran- medical students in any of the Northern Cyprus universities. Our ge from 3% in the USA to 58% in Japan (4). aim is to find medical students’ smoking status in a university of the TRNC as part of the collective work for decreasing tobacco In a 2007–2008 study in the Turkish Republic of Northern Cyprus smoking among medical students who will be future doctors. (TRNC), the prevalence of lifetime smoking among university students was found to be 69.5% (17). There is no study conducted Short-Term Aims yet on the smoking status of only medical students in the TRNC. 1. To determine the prevalences of smoking and other tobac- On the other hand, the prevalences among medical students in co products use among medical students, various surveys were found to range between 30% and 40% in 2. To find some clues about the influence of medical education Turkey (18-21). on smoking habits of these students, 3. To determine the association between some socio-demo- Some studies on medical students in Nigeria revealed lifetime graphic characteristics and smoking status of medical stu- tobacco used to be 9.6%–10.5% (22, 23). A 2004 study in Syria on dents. cigarette smoking among university students found the preva- lence to be 22.8% and a 2007 study on medical students to be LONG-Term Aims 10.9% (24, 25). 1. To raise awareness about the problem of smoking among medical students in general, In Jordan, studies on university students found the prevalences 2. To provide data for planning new tobacco intervention me- to be 28.6% in 2002 and 35% in 2008 (26, 27). The prevalences ans on smoking directed to students in medical schools and were found to be lower with 26% for males and 7% for females other university students, in a study among medical students in Jordan (28). 3. To provide data to assist developing activities aiming for tobacco-free university campuses in the TRNC. A cohort study conducted in Turkey in 2006 to follow-up the in- cidence of smoking during the medical education period found Background that 30% of students who were non-smokers at the time of re- Smoking is one of the leading causes of death worldwide, en- gistration to medical school have become smokers by the time ding up with the loss of 7 million lives/year; by 2030, it is estima- they reached the final grade. Most new incidences occurred ted that tobacco-related deaths will increase to approximately during the first three grades (29). In addition, the attitudes of 8 million/year (1). Counseling provided by general practitioners medical students toward anti-smoking activities were not ne- and other physicians is an evidence-based measure for tobac- cessarily positive (30, 31). co cessation (2). It is logical to assume that doctors in general, along with medical students, know best about the negative ef- Using tobacco products other than cigarettes is a worldwi- fects of smoking on leading a healthy life; nevertheless, smoking de issue that adds up to the cigarette epidemic. Water pipe prevalence among doctors and medical students remains rela- (narghile and hookah) is the second most consumed interna- tively high (3, 4). Thus, research on tobacco use among medical tional tobacco product (32). It is especially prevalent among professionals continues to be of utmost importance for public adolescents and university students in many countries, inclu- health in many countries. ding Turkey, Middle East countries, and the USA (33). Studies in Turkey showed that 32.7% of the university students and History of Tobacco in the World and in Turkey 28.6% of the medical students were using water pipes (34, 35). The origin of tobacco is a matter of controversy; the dispute is Other tobacco products used, even if not smoked so regularly, on whether it is Asian or American. Tobacco was brought to Eu- are cigars medwakh (dokha) and pipe (36-38). E-cigarettes or rope by ships of Christopher Columbus and friends (41). Colum- vaporizers are marketed as safer, more environment friendly bus has witnessed people smoking tobacco by pipes and also alternatives to tobacco [39]. Indeed, their prevalence is on the chewing tobacco leaves. Tobacco was named after the pipes rise, but there is no evidence as yet to consider them as he- called tobacco, which were used for smoking (42). Indians were althier (39, 40). smoking dried tobacco called petom using the pipes or con- sumed tobacco by rolling it within tobacco leaves (43). Tobacco According to our review of the current literature, to the best consumption increased rapidly after the discovery of its influ- of our knowledge, there are no studies on tobacco conducted ence on pleasure (41). exclusively among medical students in any of the TRNC uni- versities. The aims of the present study were to determine the Tobacco agriculture and consumption were prevalent in Turkey prevalence of smoking and other tobacco products use among during the Ottoman Empire and after the establishment of the medical students and to find clues for the effect of medical edu- Turkish Republic (TR) (44).
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Constituents of Tobacco Smoke form of tobacco is consumed by keeping it in the mouth for some The most frequently consumed form of tobacco is cigarette time and spitting out afterwards (53). smoking. Cigarette smoke contains >7000 chemicals, including 69 compounds known to have carcinogenic effects and 250 Nicotine Addiction and Health Consequences of Tobacco Use other toxins (10). The cigarette ingredients may be in the gas or According to the World Health Organization, tobacco is the particle phase. Tobacco smoke also contains oxidants and free second major preventable cause of death and the fourth most radicals that initiate or progress oxidative damage (45). common risk factor for disease worldwide, killing 100 million pe- ople in the 20th century and estimated to kill approximately 1 Tobacco used in the manufacture of cigarettes contains 0.5%– billion in the 21st century. It claims approximately 7 million lives/ 8% nicotine in the particle phase. Nicotine is highly addictive year; by 2030, it is estimated that the death toll will increase to and gives the smoker the feeling of being calm. Tobacco smoke 8 million/year (1). Smoking is a key issue in the medical profes- containing nicotine is inhaled into the lungs and reaches the sion, being that the doctors’ role is essential for the prevention brain in a matter of 6 s (12). Nicotine has effects on the psychia- of smoking in the community (5), and it is always taken into con- tric level; it is a stimulant in low doses, but has a paradoxical sideration in the development of overall public health policy. depressant effect in large doses, due to the blockage of the flow Smoking negatively affects just about every organ in the body of signals between nerve cells. In much larger doses, nicotine (6), along with the quality of life (7). is lethal by affecting body heat regulation, blood vessels, and hormones (13). Smokers have a higher mortality rate at all ages and also have more periods of life with acute or chronic diseases. They have The carcinogenic and other ingredients in tobacco smoke inclu- more leaves from their jobs or school attendance. Additionally, de nicotine, tar, carbon monoxide, formaldehyde, ammonia, hy- lifelong cigarette smokers have a 50% chance of dying of health drogen cyanide, arsenic, and dichlorodiphenyltrichloroethane, problems related to tobacco use. Approximately half of the as well as nitrosamines, aromatic hydrocarbons, arsenic, ben- mortality from smoking is premature deaths of the productive zene, cadmium, polonium-210, chromium, acrolein, acetaldehyde, ages. The life expectancy of smokers is approximately 10 years hydrazine, nickel, lead, cobalt, and beryllium. Polonium-210 and earlier on average than that of non-smokers according to the lead-210 in smoke are radioactive ingredients emitting alpha current research (54). particles. These radioactive isotopes deposit in the lungs and reach other organs and tissues by circulation (11, 46). The level of Unless effective tobacco control measures are taken, the present ionizing radiation has been shown to be higher in student rooms 7 million death toll will increase up to 10 million in the next 25–30 where smoking is prevalent than in non-smoking rooms (47). years, and most of the deaths will be in developing countries (1).
Forms of Tobacco Use Nicotine is a naturally occurring toxic chemical in tobacco plants Tobacco is manufactured from Nicotiana tabacum and Nicoti- causing addiction. It is a strong psychomotor stimulant causing ana rustica plants. Different forms of tobacco products include physical and psychological dependence. cigarettes, pipes (medwakh and dokha), cigars, bidi (hand- rolled cigarettes), snuff, cretex, smokeless tobacco (paan and Addiction is termed substance dependence by the American gutkha), chewing tobacco, water pipe (shisha, narghile, argila, Psychiatric Association (APA). Diagnostic and Statistical Man- and hookah), vaporizer, or e-cigarettes. In Turkey, the most prev- ual of Mental Disorders IV criteria of substance dependence alent form of tobacco use is cigarette smoking; less consumed have been defined precisely by the APA, which are all relevant forms are hookah, pipes, and cigars and, in some locations, for nicotine addiction (55, 56). hand-rolled tobacco (48, 49). Addiction is defined as a maladaptive pattern of substance use Hookah (water pipe and narghile) consumption is a form of to- leading to clinically significant impairment or distress, as mani- bacco use prevalent in Turkey, India, and Iran. Tobacco from the fested by three (or more) of the following (criteria) occurring any N. tabacum family is consumed in hookah use (49). time in the same 12-month period:
Pipe tobacco is manufactured from Virginia, Burley, Kentucky, 1. Tolerance, as defined by either of the following: and Maryland tobacco. The tobacco is subjected to other pro- a. A need for markedly increased amounts of the substance cedures for flavoring, such as aromatization (50). to achieve intoxication or the desired effect, b. Markedly diminished effect with continued use of the same Cigar is a tobacco product >3 g obtained by hand or machinery amount of the substance. rolling of cigar or cigarette tobacco. Tobacco products of the 2. Withdrawal, as manifested by either of the following: same form <3 g are called cigarillos (51). a. The characteristic withdrawal syndrome for the substance, b. The same (or closely related) substance is taken to relieve Snuff is a tobacco product of high nicotine levels in powder form or avoid withdrawal symptoms. and mixed up with aromatizing ingredients, such as bergamot, 3. The substance is often taken in larger amounts or over a clove, cinnamon, and carbonate. It is consumed by inhalation longer period than intended. through the nostrils (52). 4. There is a persistent desire or unsuccessful efforts to cut down or control substance use. Chewing tobacco is smokeless tobacco extracted from N. rus- 5. A great deal of time is spent in activities necessary to ob- tica L. and is prevalent in the southeastern part of Turkey. This tain the substance, such as visiting multiple doctors or driv-
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ing long distances, use the substance, such as chain-smok- Global Tobacco Control Measures ing, or recover from its effects. Tobacco control covers the strategies for improving public health 6. Important social, occupational, or recreational activities are by supply reduction and demand reduction measures regarding given up or reduced because of substance use. the use of tobacco products. The preventive or harm reduction 7. Substance use is continued despite knowledge of having a measures from the risks of tobacco smoke by decreasing tobac- persistent physical or psychological problem that is likely to co consumption and exposure to passive smoking are the most have been caused or exacerbated by the substance (for ex- significant of these strategies (59, 65). ample, current cocaine use despite recognition of cocaine-in- duced depression or continued drinking despite recognition The WHO Framework Convention on Tobacco Control (FCTC) that an ulcer was made worse by alcohol consumption). has been introduced by the WHO to combat the global tobac- co epidemic. The Convention entered into force on February 27, Smoking is especially hazardous to the respiratory system, 2005—90 days after it had been acceded to, ratified, accepted, causing lung cancer, chronic obstructive pulmonary disease or approved by 40 states. The FCTC had been signed by 181 par- (COPD), and other diseases. Smokers are 12–13 times more likely ties and approved by 168 countries worldwide by 2016. to die from COPD than non-smokers (8, 9). Smoking also triggers asthma attacks and facilitates lung fibrosis (8, 9). People who Core demand reduction provisions in the WHO FCTC (articles smoke even <5 cigarettes/day can develop early signs of car- 6–14) include price and tax measures and non-price measures diovascular disease. Smoking damages blood vessels and may to reduce the demand for tobacco, such as protection from ex- cause blockage of the blood vessels that reduces the blood flow posure to tobacco smoke; regulation of the contents of tobacco to the organs and skin, causing early aging, stroke, and coronary products; regulation of tobacco product disclosures; packaging artery disease (8). and labeling of tobacco products; education, communication, training, and public awareness; tobacco advertising, promotion, Smoking is a major risk for cancer in almost all the organs and sponsorship; and demand reduction measures regarding and tissues of the body, including oropharynx, larynx, trachea, tobacco dependence and cessation. Core supply reduction pro- esophagus, stomach, colon (colorectal), liver, pancreas, bone visions in the WHO FCTC (articles 15–17) are measures for illicit marrow (acute myeloid leukemia), bladder, uterine cervix, kid- trade in tobacco products, sales to and by minors, and provision ney, and ureter. Tobacco smoke also increases the risk of dying of support for economically viable alternative activities (65). from cancer and other diseases as well in patients with cancer and survivors of cancer. If nobody smoked, one of every three More than 1 billion people worldwide are currently tobacco cancer deaths in the USA would have been prevented (8, 9). product consumers, with rapidly increasing frequencies in de- veloping countries as a consequence of the population growth Cessation Therapy and promotive efforts of the tobacco industry. The six most ef- The attitudes and behaviors of parents and other role models fective policies that can curb the tobacco epidemic in line with play crucial roles in adopting, continuing, and quitting of tobac- the FCTC are outlined in the WHO’s M-POWER strategy intro- co and other addictions, especially of adolescents. Therefore, duced in 2008: Monitoring tobacco use and prevention, Protect- younger individuals should be protected from the negative in- ing people from environmental tobacco smoke, Offering help fluences of smokers in their vicinity. Children and young people to quit tobacco use, Warning people about the dangers of to- are recommended to be evaluated with their parents in depen- bacco, Enforcing bans on tobacco advertising, promotion, and dency prevention programs, especially during quitting efforts sponsorship, and Raising taxes on tobacco (66). One-third of the (57-59). world’s population (2.3 billion people) is currently covered by at least one effective tobacco control measure. The dependent person is strongly in need of using the substance either as a reward reinforcer or as prevention of the negative Tobacco Dependency among Physicians and Medical Students symptoms of withdrawal (60). Tobacco dependency is mea- The tobacco dependency among physicians is an important sured by the Fagerström Test for Nicotine Dependence and Eu- factor influencing the general population regarding the atti- ropean Medical Association on Smoking or Health dependency tudes toward tobacco use. The tobacco dependency of phy- test (61, 62). sicians may affect their attitudes and functions as role models negatively and may decrease their sensitivity for the risks of to- The evidence-based treatments for smoking addiction are bacco smoking and their behaviors toward informing their pa- cognitive and behavioral approaches and pharmacotherapy. tients on the hazards of tobacco use (67). Counseling the patients on the health consequences of smoking on withdrawal symptoms and tobacco dependency treatment Tobacco addiction prevalences have been found to be high are important aspects of cessation programs, as well as pre- among male physicians in Turkey during the 1990s. The study by venting relapse. The success of cessation treatment depends on Kosku et al. (67) in 1994 revealed a prevalence of 40% among relieving the withdrawal symptoms for which the first-line phar- residents and 32% among specialists of the Thorax Association macological agents are nicotine replacement therapy, bupropi- in Turkey. Another study in 1994 found a smoking prevalence of on, and varenicline (63). Combination therapies are available 52.8% among male doctors and 41% among female doctors (68). for serious nicotine addiction cases. There are also second-line A 2003 study in Hacettepe University Medical School showed pharmacological agents as well for the treatment of nicotine a prevalence of 37.2% among academic personnel. The preva- dependency, including nortriptyline, clonidine, rimonabant, and lence of smokers among Ondokuz Mayıs University physicians nicotine vaccine (64). was found to be 31.9% (69).
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Other country results regarding smoking among physicians re- from different countries and backgrounds, but the most frequent vealed varying prevalences: 27.1% male Japanese physicians five nationalities found were Northern Cypriot, Turkish, Nigerian, and 6.8% female Japanese doctors (70); 34% French general Syrian, and Jordanian. The prevalence of lifelong smoking among practitioners (71); 22% Danish health workers (72); and 15.8% Is- university students in Northern Cyprus in 2010 was found to be raeli physicians (73). There appears to be a need for further edu- 69.5% [16]. To the best of our knowledge, there is no study con- cation of both the medical doctors and students on the tobacco ducted on medical students cigarette smoking status in Northern issue, as well as implementing methods for cessation (74). Cyprus, whereas the prevalences among medical students were found to range approximately between 30% and 40% in Turkey Physicians’ Responsibility on Tobacco Control (17-19). In Nigeria, one study on university students revealed the The best practice is non-smoking doctors. Smoking physicians lifetime use of tobacco to be 10.5% (22), and another study in a dif- are not convincing when speaking against smoking (54). While ferent university found the lifetime use of tobacco to be 9.6% (23). taking a tobacco history, the physician should be aware that In Syria, a study discussing cigarette smoking among university only taking a thorough history is capable of quit rates of 1%–3% students in 2004 found that the prevalence was 22.8% (24), and (55). another study with medical students in 2007 found that the pre- valence was 10.9% (25). In Jordan, a 2002 study (26) in one univer- Smoking is the main issue in the medical profession, with the sity found that the prevalence among their students was 28.6%, doctors’ role being essential for the prevention of smoking in the whereas another study in 2008 (27) found that the prevalence community, which should always be considered in the develop- was 35%. A study (28) that searched for the prevalence among ment of overall public health policy (5). Researchers have shown medical students at one university in Jordan found that the pre- that medical interventions can be very effective in promoting valences were 26% among male and 7% among female students. cessation of smoking (13). Physicians are looked up to by the community, patients, and colleagues. It is only logical for doctors A cohort study conducted in Turkey in 2006 to detect the inci- to set examples by presenting a non-smoker environment in their dence of smoking during the medical study period found that clinics, offices, vehicles, and private residences (14). Since 1976, it 30% of students who were non-smokers at the time of registra- was suggested that non-smoking doctors have a better chance tion to medical school had become smokers by the time they to succeed in promoting smoking cessation (15). A review publi- reached the final grade, and that most new incidences occur- shed in 2007 (3) searched through 81 studies published between red during the first three grades (29). This suggests that univer- 1974 and 2004 about smoking among health professionals to sity education in general might be a factor for adoption of the determine smoking trend changes according to time and place smoking habit, and that medical education is insufficient for rai- (country) and has concluded that even though smoking habits sing awareness among students toward the hazards of smoking vary widely through the years and among countries, still, it is not and preventing new incidences among them. Not helping the uniformly low from an international perspective. medical education image is the fact that the attitudes of medi- cal students toward anti-smoking efforts are not 100% pro (30). The success of quitting programs is directly related to the inten- Medical students are subject to the same factors that could lead sity of physician advice. The results of studies analyzing short their equals from the same age group into smoking, such as peer counseling show mean quitting rates of 5% (3%–13%) compared pressure, family member smoking, stress, and depression (31). with those of intense interventions with mean quitting rates of 29% (13%–40%) (75, 76). Using other tobacco products is a worldwide issue that adds up to the original and bigger cigarette epidemic. Water pipe Medical Students and the Tobacco Issue (narghile) is considered the second most prevalent international Medical school students are the focus of our research since smoking fad that is not showing any sign of fading away (32). It they will later become physicians themselves, and it is prudent is especially prevalent among adolescents and university stu- to address smoking behaviors among medical students befo- dents and in many countries, including Turkey, the Middle East re preparing them to become the next health promoters who countries in Asia, and the USA (33). In Turkey, a study showed are required also to promote and help smoking cessation in the that 32.7% of the university students and 28.6% of the medical community. students were using water pipe (34). Many university students who either smoked or did not smoke water pipe have very big According to an international review of tobacco smoking misconception about the harmful aspects of water pipe (35). among medical students (4), which was conducted in 2007, the prevalence of smoking was found to range from 3% in the USA Other alternative tobacco products use of interest, even if not to a whopping 58% in Japan, suggesting that the smoking doc- smoked so regularly, are cigars (36) and medwakh (dokha) (37), tor phenomenon is going to prevail for some more time. which is a long wooden smoking pipe used in Iran and in parts of the Arab Gulf states. Pipe smoking is not as prevalent any On the other hand, medical education worldwide presents a more as it used to be (38). E-cigarettes or vaporizers (39) are need in general for more comprehensive tobacco programs in marketed as a safer, more environment friendly alternative to the curricula. A study in Cairo revealed that only 34% of the me- tobacco. Indeed, their prevalence is on the rise, but there is not dical students stated that they had tobacco control education in enough evidence to consider them as either healthier or more their medical education curriculum (77). harmful than cigarettes to overall health (40).
Our study focuses on the international program in the medical The aim of the present study was to determine the prevalence of school of NEU in Northern Cyprus. Students in the program come smoking among medical students in one of the Northern Cyprus
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universities to contribute to the collective international research data were collected from the attendees after attaining permis- about this particular issue. We will also search for alternative sion from the lecturers. tobacco product smoking trends, the influence of family mem- bers’ smoking status on medical students, passive smoking, and For the second grade, to ensure to reach as many subjects as pos- attitudes of medical students toward tobacco control measures. sible, the questionnaires were handed out to students and filled out before one of their exams had commenced, with the knowledge MATERIAL and METHODS and the permission of the doctors supervising over that exam.
Time and Location For the third grade, the questionnaires were handed out to the The study was conducted among medical students attending students during one of their laboratory classes with the knowle- the school of medicine at NEU in Nicosia, Northern Cyprus du- dge and permission of the teachers. ring November 2017 and December 2017 and January 2018 and February 2018. For the fourth grade, the classrooms were visited before the lectures started, and data were collected from the attendees Type of Study after attaining permission from the lecturers. This was a cross-sectional study. For the fifth grade, as was the case with the fourth grade, the Participants of the Study groups were visited before their classes had commenced, and The study targeted all the medical students attending the me- data were collected from the attendees. dical school in the educational year 2017–2018. Of a total of 1371 medical students, 1154 (84.2%) participated in the study. Owing to the fact that the sixth grade in this university is intern- ship, each participant was accessed one by one during their Variables of the Study working hours in the hospital to collect the data.
Independent variables Terms and definitions (78, 79) • Socio-demographic features, such as age, sex, grade, na- tionality, residence, duration of residence in Cyprus, econo- Tobacco use: Tobacco use is defined as the use of any tobacco mic status, form of payment for health care product, either smoking or smokeless (78). • Exposure to environmental tobacco smoke • Smoking among family members Current smoker: A person who smokes cigarettes occasionally or every day. Dependent variables Previous smoker: A person who used to smoke cigarettes occa- • Smoking status sionally or everyday but not anymore (smoked >100 cigarettes • Amount of tobacco consumed lifelong but not anymore). • Duration of smoking • Nicotine dependence/time of first cigarette smoked Tried smoking: A person who only tried smoking but did not be- • Use of tobacco products other than cigarettes come a smoker and has not smoked since then. • Experience of cessation treatment • Status of passive smoking Lifetime smoker: A person who either tried smoking, who used to • Smoking initiation time in relation to admission to medical smoke but doesn’t smoke any more, or who is currently smoking. school • Quitting attempts, quitting methods, and quitting success Non-smoker: A person who has not and does not smoke • Attitudes toward banning smoking in closed public areas (smoked <100 cigarettes lifelong). • Attitudes toward doctors being role models by not smoking Water pipe smoker: A person who smokes water pipe (also cal- Method of Data Collection led shisha, narghile, argila, and hookah). The survey was conducted by applying a questionnaire to be filled out by the participants under observation. The question- Cigar smoker: A person who smokes cigars. naire consisted of 20 questions, divided into two sections: so- cio-demographic features and smoking behaviors. Socio-de- Vaporizer smoker: A person who uses vaporizers or e-cigaret- mographic features consisted of nine questions on age, gender, tes. grade, marital status, background, economic status, and provi- sion of health care. Smoking behaviors included 10 questions Pipe smoker: A person who smokes tobacco pipes. Synonyms: about smoking status and initiation, tobacco products use other medwakh and dokha. than cigarettes, quitting attempts, attitudes toward smoking bans and doctors’ role model function, and family history. Quitter: A person who once used to consume tobacco products but has quit for >12 months (79). Owing to the fact that subjects belonged to different grades, data were collected differently for each grade. For the first gra- Countries by income: Classification of countries of origin and the de, the classrooms were visited before the lectures started, and first 12-year residence of the participants was done by using the
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World Bank’s new country classification by income 2017–2018 RESULTS (80). These countries included: The results are given under: 1. Socio-demographic features, — High-income countries: Cyprus, USA, Austria, Saudi Arabia, 2. Smoking habits, England, Qatar, UAE, Kuwait, Oman, Germany, Australia, 3. Relationship between socio-demographic features and and Sweden; smoking. — Upper–middle-income countries: Turkey, Libya, Iraq, Leba- non, Algeria, Iran, South Africa, Azerbaijan, Kazakhstan, Socio-Demographic Features Brazil, and Saint Kitts and Nevis; Of the 1371 medical students, 1154 (84.2%) participated in the stu- — Lower–middle-income countries: Syria, Jordan, Palestine, dy. Some socio-demographic features of the participants are Egypt, Nigeria, Sudan, Yemen, Morocco, Kenya, Philippines, shown in Table 1. The age range of the medical students was Pakistan, Bangladesh, and India; between 16 and 34 (mean 20.9) years. The female population — Low-income countries: Uganda, Somalia, and Tanzania. was 51.1%.
Countries by geographical area: Classification of countries of The nationalities and the countries of residence of the parti- origin and the first 12-year residence of the participants was cipants until age 12 years are shown in Table 2. Turkey has the done by using the WHO regions classification [81]. These coun- highest population among countries. Regarding gender, the fe- tries included: male population is 53.5% for citizens of Turkey and 47.4% for all other countries. — East Mediterranean region: Jordan, Syria, Palestine, Egypt, Iraq, Libya, Oman, Lebanon, Sudan, Pakistan, Yemen, Iran, The most frequent nationalities were Turkish by 725 (62.8%), Saudi Arabia, UAE, Morocco, Qatar, Somalia, and Kuwait; Northern Cypriot by 112 (9.7%), Nigerians by 68 (5.9%), Jorda- — European region: Turkey, Cyprus, England, Germany, Au- nians by 60 (5.2%), and Syrians by 58 (5.0%). stria, Azerbaijan, Kazakhstan, and Sweden; — African region: Nigeria, Kenya, Algeria, South Africa, Tanza- The leading countries of residence up to the age of 12 years in- nia, and Uganda; cluded Turkey (719 (62.6%)), Cyprus (119 (10.4%)), and Nigeria (68 — Americas region: USA, Saint Kitts and Nevis, and Brazil; (5.9%)). — Southeast Asian region: Bangladesh and India; — Western Pacific region: Philippines and Australia. TABLE 1. Some socio-demographic features of the students in the medical school of neu (Nicosia, December 2017–February 2018) (n=1154) Pretest Socio-demographic features n % A pretest survey was performed on 20 individuals from the 1st Age (year) (n=1140) grade students at the Dentistry School of NEU. The duration of filling out the questionnaire was approximately 15 min, and the ≤17 20 1.8 questions were observed to be readily understood by the par- 18–24 1044 91.6 ticipants. ≥25 76 6.7 Mean±SD=20.9±2.2, min=16, max=34 Permission from the Dean of the Faculty of Medicine was obtai- ned. The study was approved by the Near East University Ethics Sex (n=1146) Committee (for Research Project Evaluation Report with project Male 560 48.9 no. 482, meeting no. 2017/52, dated November 23, 2017 and Project Female 586 51.1 Evaluation Report with project no. 516, meeting no. 2018/54, dated January 18, 2018). Questionnaires were answered anonymously. Grade (n=1151) Informed consent was obtained from the participants. The par- 1st 329 28.6 ticipants were assured that research results will not be used for 2nd 287 24.9 any other but educational and scientific purposes. 3rd 300 26.1
th Data Analysis 4 118 10.3 Collected data were analyzed using Statistical Package for the 5th 84 7.3 Social Sciences version 18.0.0 software (IBM Corp.; Armonk, 6th 33 2.9 NY, USA). Descriptive statistics were expressed as frequencies, mean, median, standard deviations, and maximum and mini- Medical program (n=1154) mum values for analyzed parameters, and marginal and cross English 456 39.5 tables were made. A p value <0.05 was accepted as significant. Turkish 698 60.5 Marital status (n=1142) Limitations Since the native language of the majority of the students was Single 1119 98 not English, some of the answers might not reflect accurate in- Married 12 1.1 formation but instead what the participant thought the question Relationship 10 0.9 meant. The results of this research are limited to and represen- Divorced 1 0.1 tative of the students of the medical school of NEU.
7 Asut Ö. The Smoking among Medical Students Cyprus J Med Sci 2019; (Suppl 1): 1-21
TABLE 2. Nationality and country of residence up to age 12 years for TABLE 3. Nationalities and countries of residence according to the the students in the medical school of NEU (Nicosia, December 2017– income of the students in the medical school of NEU (Nicosia, De- February 2018) (N=1154) cember 2017–February 2018) (N=1154) Nationality Residence until age 12 years Nationality Residence n % n % n % n % Turkey 725 62.8 719 62.6 Country according to income (n=1141) (n=1149) Northern Cyprus 112 9.7 119 10.4 High income 139 12.2 231 20.1 Nigeria 68 5.9 68 5.9 Upper–middle income Jordan 60 5.2 46 4.0 764 67.0 753 65.5 Syria 58 5.0 26 2.3 Lower–middle income Palestine 15 1.3 10 0.9 Low income 238 20.9 165 14.4 Egypt 11 1.0 7 0.6 Countries according to (n=1149) (n=1149) geographical regions Iraq 11 1.0 9 0.8 Eastern Mediterranean area 206 215 18.7 Libya 10 0.9 10 0.9 European area 846 849 73.9 Oman 10 0.9 12 1.0 African area 75 76 6.6 Lebanon 9 0.8 9 0.8 Americas area 10 6 0.5 USA 8 0.7 6 0.5 Southeast Asian area 3 1 0.1 Sudan 5 0.4 – 0.0 Western Pacific area 1 2 0.2 Pakistan 5 0.4 – 0.0 Yemen 4 0.3 – 0.0 TABLE 4. Economic status and payment for health care of the United Kingdom 3 0.3 3 0.3 students in the medical school of NEU (Nicosia, December 2017–Feb- Kenya 3 0.3 3 0.3 ruary 2018) (N=1154) Iran 3 0.3 2 0.2 Economic status (n=1138) n % Germany 3 0.3 4 0.3 Low 51 4.5 Bangladesh 2 0.2 – 0.0 Medium 938 82.4 Morocco 2 0.2 1 0.1 High 149 13.1 Saudi Arabia 2 0.2 52 4.5 Form of payment for health care n %* United Arab Emirates – 0.0 19 1.7 State (n=1116) 574 51.4 Austria 1 0.1 2 0.2 Out of pocket (n=1115) 324 29.1 Qatar – 0.0 7 0.6 Private insurance (n=1116) 297 26.6 Kuwait – 0.0 5 0.4 *Row percentages over n Other 12* 2.8 8** 0.8 The duration of residence in Cyprus for the participants is *Algeria, Saint Kitts and Nevis, Philippines, South Africa, Somalia, Azer- baijan, Kazakhstan, Brazil, India, Tanzania, Uganda, and Sweden shown in Table 5.
**Philippines, South Africa, Uganda, Kazakhstan, India, Tanzania, Swe- Of the 824 responder students, 43.4% (358) had lived in Cyprus den, and Australia for 3–5 years, and 18.2% had lived in Cyprus for >5 years.
The nationalities and the countries of residence according to Smoking Habits income and WHO geographical regions grouping of the partici- Lifetime cigarette smoking status and current cigarette smoking pants are shown in Table 3. status of the participants are shown in Table 6.
High-income country nationals were 75 (12.2%), whereas resi- Students who had never smoked were 41.7%, whereas lifetime dence at high-income countries until age 12 years was 35.8% smokers were 40.7%, excluding those who only tried. Of the 1154 (162) of the participants. Nationals of upper–middle-income students, 305 (26.5%) stated that they smoked at least 1 cigarette/ countries were 764 (67.0%). day, 17.6% stated that they tried it, 7.0% stated that they once used to smoke but not anymore, and 7.2% stated that they smoked <1 cigaret- The economic status and expenditures for health care of the te/day. Current smokers were 33.7%, and non-smokers were 66.3%. participants are shown in Table 4. Cigarette smoking profile (duration, daily number of cigarettes, The economic status of the students was stated as medium by time of the first cigarette, starting smoking regarding admission 82.4%. Of the 1154 participants, 51.4% indicated state coverage to medical school, and medical grade when smoking started) of for health expenditures. the participants is shown in Table 7.
8 Cyprus J Med Sci 2019; (Suppl 1): 1-21 Asut Ö. The Smoking among Medical Students
TABLE 5. Duration of residence in Cyprus of the students in the medi- TABLE 8. Cigarette smoking quit attempt status of the smoker cal school of NEU (Nicosia, December 2017–February 2018) (N=1154) students in the medical school of NEU (Nicosia, December 2017–Feb- ruary 2018) (N=379) Residence in Cyprus (n=824) n % Quit attempt (n=379) n % <1 year 26 3.2 Yes 187 49.3 1–2 years 290 35.2 No 192 50.7 3–5 years 358 43.4 No. of attempts (n=133) >5 years 150 18.2 1 46 34.6 TABLE 6. Cigarette smoking status of the students in the medical 2 39 29.3 school of NEU (Nicosia, December 2017–February 2018) (N=1154) 3 22 16.6 Lifetime cigarette smoking (n=1152) n % 4 6 4.5
9 Asut Ö. The Smoking among Medical Students Cyprus J Med Sci 2019; (Suppl 1): 1-21
Of the total, 29.3% (335) of the students use some kind of tobac- The attitudes of the participants toward smoking ban in closed co product other than cigarettes. Water pipe (hookah) ranks first public areas and doctors being role models for the community among these by 21.9%. by not smoking are shown in Table 11.
Of the 1093 students replying to the question, 86.2% support the TABLE 10. Other tobacco products consumption among students in ban in closed public places, and 13.8% do not. Of the 1127 studen- the medical school of NEU (Nicosia, December 2017–February 2018) (N=1154) ts, 82.2% approve the role model function of doctors, but 17.8% do not. Turkish program students are more in favor of bans and Use of other tobacco products (n=1145) n %* doctors being role models (89.8% and 83.7%, respectively). Do not use 810 70.7 Total other tobacco product use 335 29.3 The smoking status of family members of the participants is shown in Table 12. Hookah (n=1113) 244 21.9* Cigar (n=1112) 59 5.3* Of the 1154 Turkish students, 435 (67%) were informed about the Vaporizers or e-cigarettes (n=1113) 29 2.6* quitline of Turkey (answered by 649 out of 698 Turkish program students). Pipe or medwakh (n=1112) 27 2.4*
*Row percentages over n Relationship between Socio-Demographic Features and Smoking Smoking status according to the gender of the participants is TABLE 11. Attitudes of the students in the medical school of NEU to- shown in Table 13. ward smoking ban in closed public areas and doctors being role mod- els by not smoking (Nicosia, December 2017–February 2018) (N=1154) Of the 387 smoker students, 42.1% and 25.8% were male and fe- Support for ban in closed public areas (n=1093) n % male smokers, respectively. Lifetime smokers were 50.4% for ma- Yes 942 86.2 les, excluding those who only tried in the past. Lifetime smokers were 31.8% for women, also excluding those who only tried. No 151 13.8 Doctors’ role model status (n=1127) Comparison of the smoking status among citizens of Turkey and Yes 926 82.2 other country citizens in the medical school of NEU are given in Table 14. No 201 17.8 Students who are citizens of the TR smoke by 37.8%, whereas TABLE 12. Smoking status of family members of the students in the other country citizens’ smoking prevalence is 26.6%. TR citizens medical school of NEU (Nicosia, December 2017–February 2018) smoke at significantly higher rates than the other country citi- (N=1154) zens (p<0.001). Smoker member of the family (n=809) n %* Father 242 29.9 The gender and age status of the participants on catching up the smoking habit in relation to admission to medical school are Mother 161 19.9 shown in Table 15. Both parents** 84 10.4 Sibling (n=808) 101 12.5 Of the 355 responder students, 61.2% of the male smokers had star- ted smoking before admission to medical school, whereas 54.4% of *Row percentages over n the female smokers caught up the smoking habit after entering the **Both parents’ value includes numbers from the father and mother, and medical school. The gender difference is significant, meaning more it is not isolated females start smoking during the medical education period than
TABLE 13. Smoking status according to gender among students in the medical school of NEU (Nicosia, December 2017–February 2018) (N=1154) Male Female Total Smoking status (n=1145) n %* n %* n % χ2 p Current smoking (n=560) (n=585) Smoker 236 42.1 151 25.8 387 33.8 34.103 <0.001* Non-smoker 324 57.9 434 74.2 758 66.2 Lifetime smoking (n=560) (n=585) Never smoked 185 33.0 290 49.6 Tried 93 16.6 109 18.6 Used to smoke 46 8.2 35 6.0 At least 1 cigarette/day 197 35.2 107 18.3 <1 cigarette/day 39 7.0 44 7.5 *Row percentages
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TABLE 14. Comparison of the smoking status among citizens of Turkey and other country citizens in the medical school of NEU (Nicosia, December 2017–February 2018) (N=1154) Smoker Non-smoker Country (n=1152) n % n % χ2 p Turkey 274 37.8 450 62.2 Others 114 26.6 314 73.4 15.132 <0.001 Total 388 33.7 764 66.3
TABLE 15. Time of initiation of smoking regarding entrance to the medical school in relation to gender and age of the smoker students in the medi- cal school of NEU (Nicosia, December 2017–February 2018) (N=388) Initiation Before admission After admission Feature n % n % χ2 p Sex (n=355) 41.2 <0.001 Male 126 61.2 80 38.8 Female 68 45.6 81 54.4 Age group (year) (n=354) 13.9 p=0.011 <25 175 56.5 135 43.5 ≥25 18 40.9 26 59.1
TABLE 16. Smoking status of the students in the medical school of NEU in relation to nationality and countries of residence up until the age of 12 years with country groupings according to income and WHO geographical region (Nicosia, December 2017–February 2018) (N=1154) Initiation Smoker Non-smoker Feature n %* n %* χ2 p Country of origin (nationality) grouped according to income (n=1140)
High 36 24.0 114 76.0 19.179 <0.001 Upper–middle 284 37.8 468 62.2 ** Lower–middle and low 64 27.2 171 72.8 Country of residence until age 12 years according to income (n=1148)
High 38 25.0 114 75.0 21.575 <0.001 Upper–middle 311 37.4 520 62.6 ** Lower–middle and low 37 22.7 126 77.3 Country of origin grouped according to region (n=1140) East Mediterranean 74 35.9 132 64.1 Europe 304 36.0 541 64.0 Africa 2 2.7 73 97.3 Americas 4 40.0 6 60.0 Southeast Asia – 0 3 100 Western Pacific – 0 1 100 Country of residence until age 12 years grouped according to region (n=1148) East Mediterranean 77 35.8 138 64.2 Europe 301 35.5 547 64.5 Africa 2 2.6 74 97.4 Americas 5 83.3 1 16.7 Southeast Asia – 0 1 100 Western Pacific 1 50.0 1 50.0 *Row percentages **Likelihood ratio
11 Asut Ö. The Smoking among Medical Students Cyprus J Med Sci 2019; (Suppl 1): 1-21
TABLE 17. Smoking status of family members of smoker and non-smoker students in the medical school of NEU (Nicosia, December 2017) (N=1154) Smoker Non-smoker Family members n % n % χ2 p Father (n=809) Smoker 125 51.7 117 48.3 <0.001* Non-smoker 161 28.4 406 71.6 Mother (n=809) Smoker 82 50.9 79 49.1 <0.001* Non-smoker 204 40.1 444 68.5 Both parents (n=809) Smoker 50.0 59.5 34 40.5 <0.001* Non-smoker 236 32.6 489 67.4 Siblings (n=808) Smoker 46 45.5 55 54.5 5.9 0.052** Non-smoker 240 33.9 467 66.1 *Fisher’s exact test **Likelihood ratio
TABLE 18. Other tobacco product use according to cigarette smoking among students in the medical school of NEU (Nicosia, December 2017–Feb- ruary 2018) (N=456) Smoking* Not smoking* Family members n % n % χ2 p Other tobacco product consumption (n=1144) Yes 222 66.3 113 33.7 <0.001** No 162 20.0 647 80.0 Other tobacco product users Hookah (n=1112) 153 62.7 91 37.3 <0.001** Cigar (n=1111) 49 83.1 10 16.9 <0.001** Vaporizers or e-cigarettes (1112) 21 72.4 8 27.6 <0.001** Pipe or medwakh (1112) 23 85.2 4 14.8 <0.001** *Smoking and not smoking are only for cigarette smoking **Fisher’s exact test
males. Similarly, the older population group of ≥25 years started zens in the English program of the medical school, 41.5% were smoking more by 59.1% after entrance to the medical school. smokers, ranking first among country regions, similar to the re- sults of the total group with 36%. Table 16 shows the smoking status of the students according to their nationalities and countries of residence up until the age of The status of the smoking features of family members in relation 12 years, countries grouped according to income and WHO ge- to the smoking of students is shown in Table 17. ographical region. Smoking of the mother and/or the father is closely related to In summary, 24.0% of the citizens of high-income countries, 37.8% the smoking status of the child. The offsprings of smoker parents of the citizens of upper–middle-income countries, and 26.9% of smoke at significantly higher rates than those of non-smoking the citizens of lower–middle- and low-income countries were parents (p<0.001). smokers. Smoking was significantly higher among upper–mid- dle-income country citizens (χ2=19.2, p<0.001). The smoking rate The use of tobacco products other than cigarettes in relation to was similar (36.7%) for upper–middle-income country citizens in the smoking status of the participants is shown in Table 18. the English program of NEU Medical School as well; thus, the high rate is not due to TR citizens only. The use of other tobacco products is closely related to smoking cigarettes. Cigarette smokers use all other tobac- Regarding the regional distribution of countries of origin and co products at significantly higher levels than non-smokers. residence until the age of 12 years, smoking rates were lowest However, 37.3% (91 students) of hookah users are not cigaret- among citizens of African countries. Of European country citi- te smokers.
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TABLE 19. The comparison of the smoking and non-smoking students in the medical school of NEU regarding their attitudes toward banning smoking in closed public areas and toward doctors being role models for the community (Nicosia, December 2017–February 2018) (N=1154) Smoker Non-smoker Family members n %* n %* χ2 p Positive attitude toward ban in closed areas (n=1092) Yes 287 78.8 654 89.8 <0.001** No 77 21.2 74 10.2 Positive attitude toward role model function of doctors (n=1126)
Yes 248 66.7 678 89.9 <0.001** No 124 33.3 76 10.1 *Column percentage **Fisher’s exact test
TABLE 20. The gender distribution of the attitudes of the participants TABLE 22. The attitudes regarding doctors being role models by not of the medical school of NEU regarding doctors’ status as non-smok- smoking of the participants according to the grade in the medical ing role models (Nicosia, December 2017–February 2018) (N=1154) school of NEU (Nicosia, December 2017–February 2018) (N=1154) Role model function Role model function Yes No Yes No n %* n %* %2 p n % n % Gender (n=1120) Grade (n=1124) Male 423 78.2 118 21.8 0.001** 1st 270 82.8 56 17.2 Female 497 85.8 82 14.2 2nd 234 85.1 41 14.9 *Row percentage 3rd 232 80.6 56 19.4 4th 101 85.6 17 14.4 TABLE 21. Smoking status of the participants according to the grade 5th 68 81.0 16 19.0 in the medical school of NEU (Nicosia, December 2017–February 2018) (N=1154) 6th 19 57.6 14 42.4 Smoking status The gender distribution of the attitudes of the participants re- Non-smoker Smoker garding doctors’ status as non-smoking role models is shown n % n % in Table 20. Grade (n=1149) 1st 237 72.5 90 27.5 Male students who think that doctors should be role models for the community by not smoking were 78.2%, whereas 85.8% of nd 2 170 59.2 117 40.8 females shared this view. The difference between the two gen- 3rd 195 65.0 105 35.0 ders was statistically significant (p=0.001). 4th 77 65.3 41 34.7 Table 21 shows the smoking status of the participants according 5th 58 69.0 26 31.0 to the grade of medical school. 6th 25 75.8 8 24.2 Total 762 66.3 387 33.7 The attitudes regarding doctors being role models by not smoking of the participants according to the grade in the medi- The attitudes of smoker and non-smoker participants regarding cal school of NEU are shown in Table 22. smoking ban in closed public areas and doctors being role mo- dels for the community are shown in Table 19. The low percentage of positive attitudes in the 6th grade does not comply with the smoking status of these students, the Smoker students who supported the ban on smoking in clo- smoking rate being lowest by 24.2% among the 6th-year stu- sed areas were 78.8%, whereas non-smoker students who dents. supported the ban were 89.8%. Non-smokers who suppor- ted banning smoking in closed public areas are more than The attitudes toward smoking ban in closed public areas of the smokers who supported the ban; the difference is statistically participants according to gender are shown in Table 23. There is significant (p<0.001). Similarly, 66.7% of smokers and 89.9% of no significant gender difference regarding this issue. non-smokers stated that doctors should be role models by not smoking. This difference is also statistically significant The attitudes toward smoking ban in closed public areas of the (p<0.001). participants according to their grade are shown in Table 24.
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The attitudes of the participants regarding doctors being role Female students comprise 53.5% of Turkish students, whereas models by not smoking according to their nationalities and females are 47.2% of other country students. country of residence until age 12 years are shown in Table 25. Countries are grouped according to income [79]. Smoking status of the Turkish citizens according to gender is shown in Table 27. Of the students from high-income countries, 79.0% agree that doc- tors should be role models by not smoking, as do the 81.1% from up- Of the 1154 Turkish students, 45.2% of males and 31.4% of fema- per–middle-income countries and 87.4% from lower–middle- and les are smokers. Smoking frequency is higher among Turkish stu- low-income countries. The differences among the groups are not dents than the overall frequencies that are 42.1% for males and statistically significant according to the nationality of the students. 25.8% for females.
Comparison of the gender status regarding Turkish students DISCUSSION and other country citizens in the medical school are presented The smoking and other tobacco product consumption features in Table 26. of the medical students studying in the NEU School of Medicine were studied in this cross-sectional study. Of a total of 1371 medi- TABLE 23. Attitudes of the students toward smoking ban in public set- cal students, 1154 (84.2%) responded to the questionnaire. tings according to their gender in the medical school of NEU (Nicosia, December 2017–February 2018) (N=1154) In the present study, students who never have smoked were Ban support 41.7%, whereas lifetime smokers were 40.7%, excluding those Yes No who only tried. Of the 1154 students, 305 (26.5%) stated that they n % n % smoked at least 1 cigarette/day, 17.6% stated that they tried it, Gender (n=1086) 7.0% indicated once smoking but not anymore, and 7.2% stated smoking <1 cigarette/day. The total of daily and occasional (cur- Male 441 84.3 82 15.7 0.095* rent) smokers was 33.7%, and non-smokers were 66.3%. Female 495 87.9 68 12.1 *Fisher’s exact test In a joint study of USA Brown University and Italian Bologna University medical schools, the smoking prevalence was 29.5% TABLE 24. Attitudes of the students toward smoking ban in closed in Bologna University, which is lower but close to our results, public areas according to their grades in the medical school of NEU whereas it was much lower in Brown University with 6.1% (82). (Nicosia, December 2017) (N=1154) Ban support According to a systematic review in 2007, the lowest prevalenc- Yes No es with 2%–4% were found among medical students of Amer- ica, Australia, China, and India during the late 1990s. In various n % n % χ2 p studies, prevalences were <10% in these countries and also in Grade (n=1090) Thailand and Malaysia. On the other hand, high smoking rates 1st 263 83.8 51 16.2 8.03 0.16 were prevalent among male medical students in Greece (41%) 2nd 222 83.5 44 16.5 and Spain (42%) (4).
rd 3 256 90.1 28 9.9 In a cross-sectional study conducted in 2009 among medical 4th 100 87.0 15 13.0 students of 12 European countries, including Germany, Italy, Po- 5th 72 90.0 8 10.0 land, and Spain, the mean smoking prevalence was 29.3%, with the lowest rate in Germany with 28.0% and the highest rate 6th 27 87.1 4 12.9 in Italy with 31.3% (83). These countries are those with higher
TABLE 25. The attitudes of the participants regarding doctors being role models by not smoking according to their nationalities and residence until age 12 years in the medical school of NEU (Nicosia, December 2017–February 2018) (N=1154) Doctor as a role model Yes No n % n % χ2 p Countries of origin according to income (n=1116) High 109 79.0 29 21.0 5.8 0.056 Upper–middle 607 81.1 141 18.9 Lower–middle and low 201 87.4 29 12.6 Countries of residence until age 12 years according to income (n=1124)
High 179 78.2 50 21.8 7.0 0.03 Upper–middle 606 82.2 131 17.8 Lower–middle and low 140 88.6 18 11.4
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TABLE 26. Comparison of gender status regarding Turkish students TABLE 27. Smoking status of the Turkish citizens according to gender and other country citizens in the medical school of NEU (Nicosia, in the medical school of NEU (Nicosia, December 2017–February December 2017–February 2018) (N=1154) 2018) (N=725) Gender Smoking status Male % Female % Total Gender Non-smoker % Smoker % Total Citizens of all other countries 224 52.8 200 47.2 424 Male 184 54.8 152 45.2 336 Citizens of Turkey 336 46.5 386 53.5 722 Female 263 68.3 122 31.4 385 Total 560 48.9 586 51.1 1146 Total 447 62.0 274 38.0 721 prevalences of smoking in Europe, and the higher prevalences The progress in tobacco control and the evidence mounting on among medical students are a reflection of the general popula- the health consequences of smoking showed dramatic declines tion. A study from Egypt has shown similar characteristics with in the prevalences of smoking doctors, especially in high-income our study regarding non-smokers comprising the majority, but countries. Medical doctors smoke less than dentists and nurses. 46.7% had smoked for some time in their lives, and 35% were The lowest smoking prevalences for physicians are seen in the current tobacco users (84). USA, Australia, and the United Kingdom. Similarly, the smok- ing prevalences of Japanese doctors decreased dramatically Smoking the first cigarette in the first 30 min upon waking up is from 66.0% to 7.0% during 1965–2009, with higher decline rates one of the indicators of nicotine dependency. According to this for males (85). The doctors of the developing world continue to criterion, 48% of the smokers were physiologically nicotine de- smoke at high rates in developing countries, similar to their na- pendent in our study. Of the smokers in our study, 51.0% adopted tive people (3). the smoking habit before entrance to the medical school, and 49.0% acquired the smoking habit after starting the medical ed- Our study has found that male students smoke at statistically ucation. Of those who started smoking at the medical school, higher frequencies than female students, with a rate of 43.5% the majority (57.0%) stated that they started smoking during the for males and 28.1% for females. The highest prevalences were first year of their medical education. None of the students had among Turkish citizens for both males and females. Similarly, started smoking at the 5th or 6th grades. a study of 12 European countries revealed higher smoking fre- quencies for males in Germany, Italy, and Spain as well, but the Approximately half of the smokers in our study had attempted smoking prevalence of Polish female medical students was hi- quitting smoking in the past, the majority tried to quit without gher than that of Polish male students (83). In some studies, the assistance, and 63.5% of these were successful. In a study of 12 smoking prevalences of female medical students are found to be European countries, the medical students were found to be in- very low, approaching zero in some countries because of cultu- formed about the nicotine preparations and some anti-depres- ral reasons (4). On the other hand, female students in the current sion drugs used for quitting smoking (83). study indicated that they started smoking during their medical education period at significantly higher levels than male students. The majority of the participants of the current study have indi- cated not consuming tobacco products other than cigarettes. The smoking status of parents and other family members was Some students (23.3%) consume water pipe, and a minority con- found to be influential on the smoking status of students in the sumes other tobacco products. There are some students who current study. The students whose fathers are non-smokers consume only water pipe (9%) without smoking cigarettes who smoke significantly less than those whose fathers are smokers. may be considered potential cigarette smokers. There is a similar association for mothers and students as well in our study. Other studies reveal similar findings regarding family Most of the participants announced the cafés and restaurants members; if the parents or siblings smoke, there is a four-fold as places of exposure to second-hand smoke. These findings in- increase in the prevalence of smoking of individuals compared dicate the violation of the legal measures in force in Northern with those whose parents or siblings do not smoke (42, 43). Cyprus, specifically in cafés and restaurants. Regarding this issue, most of the students were found to be in positive attitu- Non-smokers and female students in the current study are des toward smoking bans and doctors being role models by not in support of smoking bans at significantly higher levels than smoking, which is in compliance with other country studies (81, smokers and male students. There is a general support for 83, 84). American students were more in favor of the role model smoking bans among medical students according to various re- function of doctors (93.9%) than Italian students (74.7%) (84). search findings (86).
Therefore, medical students worldwide mostly share the opin- Most of the medical students share the opinion that doctors ion that doctors should be role models for the community by not should be non-smoking role models, whether they are smokers smoking. The fact that there are some exceptions to this finding or non-smokers themselves. However, non-smokers and female is an indicator of the insufficiency of medical education. The at- students are in a positive attitude at significantly higher fre- titudes of medical students on the role model function of doctors quencies in this respect, similar to other country studies (82, 84). and support of smoking bans are actually expected to be 100% positive. Students with negative attitudes in this respect were Global studies have also investigated the status of medical edu- 10%–16% in our study. cation curricula regarding the tobacco issue. A study from Cairo
15 Asut Ö. The Smoking among Medical Students Cyprus J Med Sci 2019; (Suppl 1): 1-21
revealed that only 34.2% of the medical students indicated hav- Country-specific smoking prevalences according to the top five ing training on cessation treatment (84). The European study nationalities revealed high frequencies for Jordanians with 50% found that only 16.5% of the students had had tobacco cessation and Turkish with 44%, followed by Syrians with 35% and TRNC treatment education (83). Contrary to this research, the medical citizens with 33%. Smoking frequency was low for Nigerian stu- program of the students in the USA–Italy study indicated high dents (1.5%) and the African region in general (3%). However, levels of tobacco education with 95.2% of the students for USA the overall smoking status in our study was higher than that in and 76.4% of the students for Italy (82). previous international research for medical students.
The current cross-sectional study evaluated the smoking beha- In Nigeria, one study on university students revealed lifetime use viors of the students of a medical school in the TRNC. The of tobacco to be 10.5% (22) and another study in a different uni- smoking prevalence was high especially for the male students versity to be 9.6% (23), which is relatively low but higher than (42%) compared with the female students (23%), with an overall the results of our Nigerian group, which may be reflecting the prevalence of 33%. Of the smokers, 50% had nicotine addiction. influence of medical education. The lifetime smoking frequency was high with 48%, although lower than in a 2014 study conducted in six universities of the A 2007 study on cigarette smoking in Syria on medical students TRNC that found lifetime cigarette smoking among students found the prevalence to be 11% (25%), way lower than our result from all faculties to be 69.5% (17). of 35% for Syrians. On the other hand, a study among medical students of a university in Amman, Jordan revealed the preva- Male students were found to smoke more than female students lences to be 26% among male and 7% among female students with the lifetime smoker frequency being 60% for male students (28). The results of Jordanian students in our study are also hi- compared with 36% for female students. The large difference gher than those in the literature available, which might be due between the lifetime smoker and current smoker frequencies to the fact that Jordanian students studying in NEU have higher among both male and female students is mainly due to the income levels than most students in Jordan. These findings indi- students who tried but fortunately did not pick up the smoking cate that the mean frequencies of smoking among students in habit. The finding that male students smoke more than female the Middle East countries remain relatively high. students is consistent with other studies’ findings (87). Even though higher education should according to literature Since our study included medical students in the English lan- decrease smoking prevalences (93, 94), our results have shown guage program, it was possible to evaluate the variations in considerable smoking onset after admission to medical school. the smoking status among students of different nationalities. Of the smokers in our study, 59% started smoking before ente- The countries were categorized according to the World Bank ring the medical school, whereas 41% started after admission. country income groups regarding the countries of origin and More men picked up smoking before the medical education pe- the countries lived in until the age of 12 years. Students from riod than women, and the difference between the sex groups upper–middle-income countries smoked the most, followed by was statistically significant. students from high-income countries, with the lowest frequen- cy for low- and lower–middle-income countries combined. Contrary to other research, a study from China found that me- Students who lived in high-income countries until the age of 12 dical students have higher rates of smoking than other students, years smoke the most with a rate of 40%. Growing up in high- but most of the smokers were found to be occasional smokers and upper–middle-income countries appears to be associa- (95). On the other hand, a study in Greece revealed that the ted with a stronger chance to become a smoker. Similarly, the smoking rate of medical students was 35%, whereas it was 50% WHO data by the World Bank income group reveals that the for other students (96). These results were statistically signi- smoking rates for male adults are highest in upper–middle-in- ficant, but male medical students in the 4th grade and above come countries with 43% and highest in high-income countries smoked more than students from other schools (96, 97). for female adults with 18% (88). It appears that the richer the country the students were living in, the higher the chance for The association of the status of tobacco dependence and in- them to be smokers. terventions through education and other programs has been investigated in a number of national and global studies. Current On the other hand, a recent meta-analysis in 2016 found that tobacco use was lower among public college students who had cigarette smoking was significantly associated with lower in- attended high school in Massachusetts and who had been ex- come worldwide, suggesting a change in smoking trends ac- posed to the Massachusetts Tobacco Cessation and Prevention cording to income (89). Lower socio-economic status is related Program (MTCP) during high school than those who had attend- with increased smoking rates, which is probably due to less ed high school in another state (31.5% vs. 42.6%, p=0.006), which education levels (90). Even though our findings are consistent persisted after the necessary adjustments. The MTCP may have with the WHO data by the World Bank income group (88), the reduced tobacco use among this group of young adults (98). results of our students may not be reflective of the smoking This may also be relevant for the influence of medical education status of other students in their native countries. NEU is a pri- on medical students. vate university, and most students come from higher socio-e- conomic families affected less by the costs of smoking (91). A cohort study conducted in Turkey in 2006 to monitor the in- However, smoking people of lower socio-economic status are cidence of smoking during the medical education period found more responsive to changes in cigarette prices and less to he- that 30% of non-smoking students at registration have beco- alth publicity (92). me smokers by the time they reached the final grade, and that
16 Cyprus J Med Sci 2019; (Suppl 1): 1-21 Asut Ö. The Smoking among Medical Students most new incidences occurred during the first three grades (29), ardized tobacco education is needed for the medical education which is similar to our study. This suggests that the university process at a global perspective (104). education period in general might be an influential factor for the adoption of the smoking habit, and that medical education The first program integrating tobacco control across all years of is insufficient for raising awareness among students toward the medical education in a low- or middle-income country was re- hazards of smoking and preventing new incidences. Additional- ported from India. The development, pretesting, and piloting of ly, the attitudes of medical students toward anti-smoking efforts an innovative modular tobacco curriculum have been presented are not 100% positive (30) as was also true for our study. Medical in 2015 by Yamini at al. (105). Fifteen modules were developed students are subject to the same factors that lead their equals focusing on the impact of tobacco control on public health, to- into smoking, such as peer influence, smoking family members, bacco hazards for specific organ systems, diseases related to stress, and depression (31). smoking and chewing tobacco, and the influence of tobacco on medication effectiveness. Training videos on cessation were Tobacco Control and Medical Education prepared on specific diseases (105). Data on medical students imply the inadequacy of the medical education in both prevention and also ending the smoking habit Similarly, a tobacco control and cessation program has been among medical students. Thus, there is a necessity for assessing introduced and implemented for the past 3 years (2015–2018) in the status of medical education and curricula regarding the to- the public health committee of NEU medical education curricu- bacco issue worldwide. lum. The program starts in the first year, continuing in the third year, and ending up with the internship program in the sixth An international survey searched for tobacco education in me- year. The tobacco control program consists of all aspects of dical schools on a country basis (99). The survey investigated comprehensive tobacco control and interventions with special medical schools from 109 countries with a response rate of 32% emphasis on tobacco cessation. The first year program consists from medical schools and 64% from countries. Of the respon- of lectures on health consequences of tobacco use and doctors’ dent 665 medical schools, 39% were from developed, and 28% role in cessation and tobacco control. The third-year tobacco were from less developed countries. Of the 561 medical schools education is a multidimensional program on all aspects of com- responding to questions on teaching options, 27% indicated te- prehensive tobacco control and treatment of nicotine addiction, aching a specific module on tobacco, 77% integrated tobacco consisting of lectures and class practices. During the sixth year, education with other topics, 31% included tobacco information the internship program includes a student-centered interactive in some subjects related to the tobacco issue, and 4% did not module on tobacco control and smoking cessation with prac- teach about tobacco at all. The most common topics in the pro- tical aspects to develop the skills of the students to assist their grams were health consequences of tobacco use (94%), health patients to quit smoking. effects of passive smoking (84.5%), epidemiology of tobacco use (81%), nicotine dependence (78%), and taking a smoking The methods of the tobacco control program include main- history (75%). The most popular methods were lectures, case ly lectures, group studies, case study discussions, behavioral study discussions, problem-based learning exercises, and pa- counseling exercises, and role plays on cessation, health edu- tient-centered approaches, such as role plays. The present stu- cation, and promotion. Although the attitudes of the students dy showed a progress of tobacco education in medical schools over the previous 10 years worldwide (57, 58), although far from regarding the tobacco issue are positive, their behaviors have being sufficient, taking into account the non-respondent schools not changed much as is shown by the high prevalence of smok- that probably have less or no tobacco education in their curri- ers in the study. cula (99, 100). The results of the present study and continuous monitoring af- In a survey of fourth-year medical students at some schools in terwards may highlight the efficacy of tobacco education in the New York City, the medical students were found as aware of the prevention of smoking among medical students of NEU in the harms of smoking, but 64% of the students stated their capabili- future and may help developing new programs for this end. The ty to assist patients in cessation and treating nicotine addiction inclusion of medical students themselves in the tobacco control as inadequate (101). activities in the university, including smoke-free campuses, may facilitate the decline of the smoking prevalence among medical Another study in the USA investigated the first- and third-year and other students in the university. medical students of 10 medical schools regarding extensive to- bacco education. The tobacco education in these schools in- Our study has limitations. Since the native language of the ma- cluded a web-based course, a role-play classroom demonstra- jority of the students is not English, some of the answers might tion, and a clerkship booster session, which was found as more not reflect accurate information but instead their perception of efficient than classic training hours (102, 103). the questions. The results of this research are limited to and rep- resentative of the students of the medical school of NEU. Learning is optimal when knowledge and experience is taught early, reinforced consistently, and integrated through all aspects CONCLUSION of a curriculum (103). Early education on tobacco dependence The smoking prevalence among medical students in the current treatment skills using “didactics, preceptor modeling, patient study was high. The overall smoking status in our study was hi- observation, instruction with receipt of feedback, behavioral gher than that in most of the previous international research for counseling” may be helpful tools for medical students. A stand- medical students.
17 Asut Ö. The Smoking among Medical Students Cyprus J Med Sci 2019; (Suppl 1): 1-21
More than half of the male students had started smoking be- The intension is monitoring the changes in years of the relevant fore their medical education era. On the other hand, more than features of the medical students after the inclusion and consi- half of the female students indicated starting smoking after en- stent implementation of the new tobacco education program trance to the medical school. The results regarding female stu- introduced into the medical curricula to contribute to global me- dents reveal the significance of the early initiation of tobacco dical education and tobacco control. control education in the medical schools. Ethics Committee Approval: Ethics committee approval was received for Water pipe is the second most common tobacco product con- this study from Near East University Ethics Committee. sumed by the students. Sixty students were consumers of wa- ter pipe but not cigarettes, indicating a risk of future cigarette Informed Consent: Informed consent was obtained from the patients who participated in this study. smoking addiction. Conflict of Interest: The author have no conflicts of interest to declare. The findings of the present study point out the need of more consistent and comprehensive tobacco control education in the Financial Disclosure: The author declared that this study has received no medical schools, as is also emphasized in the current literature. financial support. The education on tobacco should include knowledge, attitude, and behavioral aspects, including personal and community REFERENCES approaches, as well as skills for the cessation of smoking. The 1. World Health Organization. WHO report on the global tobacco medical curricula should be revised according to the needs of epidemic 2017. 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